Notification Issue Date:

Medicare Advantage Policy

Title:Instrument-Based Vision Screening
Policy #:MA07.048a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.

The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.


Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company considers instrument-based vision screening to be an integral part of the Evaluation and Management Service and is, therefore, not eligible for reimbursement whether billed alone or in conjunction with other services. Participating providers may not bill members for this service.
Policy Guidelines

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.


Subject to the terms and conditions of the applicable Evidence of Coverage, instrument based ocular vision screening is covered under the medical benefits of the Company's Medicare Advantage products.


Several devices have been approved by the FDA as ophthalmic refractometers, including the MTI PhotoScreener™ (Medical Technology and Innovations, Inc.; Riviera Beach, FL).


Instrument based vision screening is an alternative vision screening method to detect the risk factors for amblyopia, which include strabismus (a misalignment of the eyes in any direction), media opacities (eg, cataracts), and refractive errors (eg, myopia, hyperopia, astigmatism, presbyopia). It consists of photoscreening and autorefraction.

Photoscreening is a technique that uses the principle of photorefraction, in which the refractive state of the eye is assessed via the pattern of light that is reflected through the pupil. In photoscreening, optical images of the eye’s red reflex to estimate refractive error, media opacity, ocular alignment, and other factors, such as ocular adnexal deformities (eg, ptosis), all of which put a child at risk for developing amblyopia. Performed in a darkened room, photoscreening requires little cooperation from the individual, other than fixating on a target for the duration of the screening process. Images of the pupillary reflexes (autonomic reflex constrictions caused by light) and red reflex (a circular red light reflected from the retina of the eye) are obtained. The photographs can then be analyzed by the evaluator or sent to a central laboratory for analysis by an ophthalmologist or specially trained personnel. Test results are typically graded as pass, fail, or if the procedure must be repeated if results are equivocal.

Autorefraction is a technique that uses several types of automated methods (eg, optically automated skiascopy or wavefront technology) which evaluate the refractive error of each eye. Data from autorefraction yield numeric results that are analyzed by the evaluator or by the instrument itself to determine if a child passes or fails the screening.


Member's Evidence of Coverage


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.

ICD -10 Diagnosis Code Number(s)


HCPCS Level II Code Number(s)


Revenue Code Number(s)


Coding and Billing Requirements

Policy History

11/04/2015This is a coding update

01/01/2015This is a new policy.

Version Effective Date: 01/01/2016
Version Issued Date: 01/05/2016
Version Reissued Date: N/A